midnightsun1369
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Hello,
Provider sees pt in hospital setting, cc is shortness of breath, all HPI information documented pertains to pulmonary. Under Impression/Plan: provider lists these dx's
1.COPD - acute exacerbation 2. S/P left shoulder replacement 3. Prostatic carcinoma 4. DJD 5. Peripheral edema
My question is: since all information ultimately directs me to the conclusion that the provider only saw the pt for pulmonary reasons, would I code all other dx also? I others do not get coded is there a guideline on this, how would I know this?
Thanks for your reply.
Provider sees pt in hospital setting, cc is shortness of breath, all HPI information documented pertains to pulmonary. Under Impression/Plan: provider lists these dx's
1.COPD - acute exacerbation 2. S/P left shoulder replacement 3. Prostatic carcinoma 4. DJD 5. Peripheral edema
My question is: since all information ultimately directs me to the conclusion that the provider only saw the pt for pulmonary reasons, would I code all other dx also? I others do not get coded is there a guideline on this, how would I know this?
Thanks for your reply.